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FOR OFFICE USE ONLY <br /> <br />City ZQolnlt Validation: ~j~ .... <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Sb-eet NE <br /> Salem, OR 97301 <br /> <br />8:00 a,m,-4:aOp.m. Phone 588-5147 <br />Code-A-Phone 588-7g04 <br /> FAX 588-7948 <br /> <br />FOR OFFICE USE ONLY <br /> <br /> DWELLING/STRUCTURAL AND/OR SEPTIC PERMIT APPLICATION <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. Job Description <br /> <br />RESiI)ENTIAL <br /> ] N~wSFDw/garag¢ <br /> ] NewSFDw/og~rage <br /> ] Addition <br />[,/f'-kltoration <br /> <br /> COMMERCIAL <br /> [ ] AcccsmB, [ ] New <br /> [ ] Relocate [ ] Addition <br /> [ I Demo [ ] Akcration <br /> <br /> Usc of Building: <br /> <br />2. Location of installation <br /> <br />Sob Ad&ass ~'--'"' ~_q 0 -'~" - .'qt.'~ ~ . ' .... Tm Acer, No,~ ~ Crc'ss Street <br /> Site No. <br />Mobfl~ l'Imc Park S~ 8 <br /> <br />~t Width 5~ ~t I);~ Ac~, Incg. Lot Comer" Pfiwta Wa~ [ ] Sprb,g <br /> ~ ~ ComnmnityW~ [ ] City <br /> <br />Contractor Information <br /> <br />5. Fee Schedules <br /> <br /> ~\~, Oo*. '~.'~¢0q <br /> Auth. Agcnt/Leasee Mailing Address & Phone No, <br /> <br /> C~tmcmr Business Name & ~um~t Mail~ Address & ~on~ ~ <br /> <br />4. Septic Information (Check where appliceble) <br /> <br /> Propos~ NO, Bcdr~m~: ~ist~g No. Bedrid; ~ New ~Uation ~ <br /> <br />Proposed Site Evaluation [] <br /> <br />Test lloles Ready [] Will Call When Test Holes Ready [] <br />Existing Site Eva/uafion [] Existing Site Evaluation No.: <br />Proposed Installation Pennk [] <br />Existing Septic System ~ <br />Existing Drainticld Length: Tank Size: <br /> <br />Date Tank Last Pumped: ~(~M . \%~ <br /> <br />~I' I have read this application in its entirety ~md ccnlfy that the stated information <br /> <br /> I am performing work on a property I own or occupy. <br /> I am a registered builder OR [ ] the authorlged representative of a registered <br /> builder, <br /> Thc work }will bt perfo~n?ed by a registered builden <br /> <br />vii agree to build accori~g to the submitted plans and spacifica[ion~ thc taws of <br /> <br />A. New One-and-Two Family Dwelling Code ValuaU0n: <br /> (inclndes El, Me, <br /> <br />(1) Sq. Ft. -- x ,28 <br />(2) 5% State Surcharge 605 x Al) <br />(3) Ease Fcc for l'inn Review <br />(4) Zoning Sumharge (If Applicable) <br /> <br />B, Structural Pcnni£ <br /> (Permit fcc determined by valuatlo~l, <br /> El, Mc, PI am ~eparate permits.) <br /> <br /> (I) Permit Fee <br /> ~2) 5% State Surcharge (,05 x B 1 ) <br /> O) Zoning Surcharge 605 x B1) <br /> (4) l'inns Check (.65 x BI) <br /> <br />Subtotal: $ <br /> <br />C, Septic Foes 0hcludes DEQ Surcharge) (1) Site Evaluation <br /> (2) New Septic installation Purmlt <br /> (3) Authorization Notice <br /> (4) Existing System Report <br /> (5) Major Repaie <br /> Minor Repair (tank only) <br /> <br />D, Miscel]ancous Fees (1) Driveway w/curb @ $7.50 <br /> (2) Driveway w/o curb @ $17 00 <br /> (3) Site Plan Review (cC~nmercial only) @ $79.00 <br /> (4) Investigation Fee <br /> (5) Reinspection Fee @ $25.00 <br /> (6) Other inspections not Itstod above <br /> <br />I85,00 <br /> <br />Subtotal: $~"~ <br /> <br /> <br />